Creating a Diagnostic Safety Net

The following is an interview with Nancy Gin, MD and Timothy Ho, MD, MPH, FAAFP, CPHQ. Dr. Gin is the executive vice president of quality and chief quality officer for The Permanente Federation, the umbrella organization for nearly 23,000 physicians nationwide in eight Kaiser Permanente regions caring for more than 12.3 million members. She also serves as the medical director of quality and clinical analysis for the Southern California Permanente Medical Group (SCPMG), leading quality and patient safety for 4.4 million Kaiser Permanente members in Southern California. Dr. Ho is the regional assistant medical director for quality & complete care at SCPMG. As a family medicine doctor & physician leader, Dr. Ho’s work focuses on achieving effective, efficient, equitable, safe, timely and patient-centered care for every person and every community.

 

Kaiser Permanente engages in many activities to improve diagnosis, but tell us about your efforts at SCPMG specifically.

“Given the pace of medicine and the complexity of symptoms and systems, we know there are many places along the path to a timely and correct diagnosis where the next step can be missed, especially in testing,” said Timothy Ho, MD, MPH, FAAFP, CPHQ. “We wanted to create a safety net to prevent test results or actions from falling through the cracks at SCPMG, thereby reducing diagnostic errors.”

That’s why SCPMG developed SureNet under the leadership of Dr. Michael Kanter, now Chair of Clinical Sciences at the Kaiser Permanente School of Medicine. SureNet is a program that uses Kaiser Permanente’s robust electronic health record data to identify patients with test results or symptoms/signs that generally require a next step or follow-up, and flags when the patients haven’t received it.

“One example is our program for abnormal creatinine results,” said Dr. Ho. “High levels of creatinine may be a sign of a kidney problem. Without additional tests, the discovery of the problem could be significantly delayed or missed.”

A study of the program’s success found that from February 2010 to March 2014, SureNet identified 12,396 individuals who had abnormally high levels of creatinine but hadn’t been referred for additional testing. More than half of those individuals, 6,981, received a repeat measurement, and 3,668 individuals were found to have some stage of chronic kidney disease.

SureNet has been so successful that other organizations like Brigham and Women’s Hospital have partnered with Kaiser Permanente to develop similar programs. There are now more than 50 programs within the SureNets of Kaiser Permanente regions nationwide.

 

What are some of the challenges associated with implementing a system like this?

“One risk in launching a SureNet program is that you may uncover a backlog of missed tests, and revealing the extent of the issue can paralyze a program from moving forward,” said Nancy Gin, MD. “We always anticipate that there will be some kind of backlog when starting a new program, so we increase the resources at the start to move those cases out faster. Once running, the number of cases gets smaller, and you can then reduce resources to maintain the ongoing flow of new information.”

Often, the more challenging task is getting providers on board to have difficult conversations with patients whose results may be several years old.

“Our clinicians understand that we aren’t blaming them, but that we need to have these conversations in order to ensure the best care for our patients,” said Dr. Ho. “So, we make sure doctors are trained and feel supported in this process.”

“Some physicians were reluctant to support the work of SureNet at first, but now it is part of our organizational culture,” he continued. “Anyone interested in launching a SureNet program should focus on training the staff who are working on these initiatives. It will never make its way into the organization’s fabric without physician support.”

 

How did you achieve physician buy-in?

“We led with the data,” said Dr. Gin. “We compared how we’re doing with how an evidence-based practice should be doing to demonstrate the gap in that aspect of our care. That opens the conversation for what we should do differently.”

Dr. Ho and his team then develop SureNet systems that are tailored to the issue at hand, ensuring that the programs do not place undue work or blame on the physicians.

“Historically, physicians have been trained to believe that they are solely responsible for the outcomes of their patients,” said Dr. Gin. “We want them to know that they can still be captain of the ship, but that doesn’t mean they have to row the boat alone. That’s why we created automated systems and an integrated infrastructure to relieve some of that pressure from physicians and increase trust that those systems reliably enhance their patients’ care.”

 

What other advice might you give to organizations interested in setting up this type of program?

“It is important for organizations to assess their culture, data, and bandwidth to determine which programs can make the biggest impact and which they can maintain long-term,” said Dr. Ho.

Once SureNet programs become part of an organization’s safety net, they can never be ‘turned off.’ That’s why it’s important to be strategic about where to start.

Dr. Ho and Dr. Gin recognize that not all organizations have the same resources and systems as Kaiser Permanente, but they agree that shouldn’t stop anyone from launching their own SureNet programs.

“If an organization doesn’t have access to clinical data, for example, they likely still have client data or administrative data that they can piece together,” said Dr. Ho. “We encourage organizations to consider moving forward with launching a SureNet program, regardless of whatever barriers they may perceive. It can be done.”

 

Resources

Additional News Articles about SureNet:

• SIDM: Overview of SureNet: Identifying Failure to Close the Loop on Abnormal Test Results or Symptoms
• Kaiser Permanente: Overcoming Care Gaps for Chronic Kidney Disease Patients
• EHR Intelligence: Harnessing Effective EHR Use for Improved Patient Care

Journal Articles:

• The American Journal of Medicine: Kaiser Permanente Creatinine Safety Program: A Mechanism to Ensure Widespread Detection and Care for Chronic Kidney Disease
• The Permanente Journal: End-Stage Renal Disease Outcomes Among the Kaiser Permanente Southern California Creatinine Safety Program (Creatinine SureNet): Opportunities to Reflect and Improve
• The American Journal of Health-System Pharmacy: Design and Implementation of Population-Based Specialty Care Programs